Non-Hodgkin's lymphoma: Is India ready to incorporate recent advances in day to day practice?

Background : Non Hodgkin\u2032s Lymphoma (NHL) cure rates are increasing and morbidities are decreasing, with more active pharmacological agents and technological advancements. In spite of this, India is still battling with the prejudices of an economically and educationally impoverished patient base. Methods and Results : We analyzed NHL cases from 2000 to 2006 using data from case sheets. Of 303 cases, only 100 patients had complete workup and received some form of treatment. For 203 patients, reasons for non-compliance were: financial constraint (119), distance from center (38), inability of physician to provide guarantees of cure (13), poor prognosis/fear of recurrence (28)), preferences for alternate medicine (5). Most common investigations that could not be afforded for staging were whole body CT scans and bone marrow aspiration and biopsy. Thirteen patients were in stage III and 53 in Stage IV. The most common regimen was CHOP (Cyclophosphamide, Adriamycin, Vincristine, Prednisolone). Forty-five patients did not complete six courses of CHOP and 35 patients had significant delay. Reasons for delay were intermittent availability of cash (35), intolerable toxicities (30), absence of supportive care (21), given-up attitudes (17). Eighty-three patients suffered Grade III/IV debilitating toxicities. Overall survival at five years was 50%. Conclusions : NHL in India is no different from the developed world. However, there are disparities in survivorship and outcomes, due to un-affordability and attitudes of the patients. Therefore, we suggest the development of Community Health Insurance Schemes (CHIs), with the hospital as the nodal center to address the above mentioned issues

Prediction of radiotherapy response in cervix cancer by Raman spectroscopy: a pilot study

Radiotherapy is the choice of treatment for locally advanced stages of the cervical cancers, one of the leading female cancers. Because of intrinsic factors, tumors of same clinical stage and histological type often exhibit differential radioresponse. Radiotherapy regimen, from first fraction of treatment to clinical evaluation of response, spans more than 4 months. Clinical assessment by degree of tumor shrinkage is the only routinely practiced method to evaluate the tumor response. Hence, a need is created for development new methodologies that can predict the tumor response to radiotherapy at an early stage of the treatment which can lead to tailor-made protocols. To explore the feasibility of prediction of tumor radioresponse, Raman spectra of cervix cancer tissues that were collected before (malignant) and 24 h after patient was treated with 2nd fraction of radiotherapy (RT) were recorded. Data were analyzed by Principal Components Analysis (PCA) and results were correlated with clinical evaluation of radioresponse. Mean Raman spectra of RT tissues corresponding to different levels of tumor response, complete, partial, and no response, showed minute but significant variations. The unsupervised PCA of malignant tissues failed to provide any classification whereas RT spectra gave clear classification between responding (complete and partial response) and nonresponding conditions as well as a tendency of separation among responding conditions. These results were corroborated by supervised classification, by means of discrimination parameters: Mahalanobis distance and spectral residuals. Thus, findings of the study suggest the feasibility of Raman spectroscopic prediction of tumor radioresponse in cervical cancers

Raman spectroscopy studies for diagnosis of cancers in human uterine cervix

Cancer of uterine cervix is one of the leading cancers among women in both developed and developing countries. Optical spectroscopy methods mostly Fourier transform infrared (FTIR) and fluorescence have widely been used to diagnose cervix cancer using cells as well as tissues. Raman spectra of normal and malignant tissues were recorded in fingerprint region. Normal cervix tissues are characterized by strong, broad amide I, broader amide III and strong peaks at 853 and 938 cm-1 which can be attributed to structural proteins such as collagen. Prominent features of malignant tissue spectra with respect to normal tissue are-relatively weaker and sharper amide I, minor red shift in ΔCH2 and sharper amide III which indicate the presence of Deoxyribonucleic acid (DNA), lipids and non-collagenous proteins. In order to develop highly objective discrimination methods, very elaborate data analysis was carried out using Principal Components Analysis (PCA). Standard sets for normal and malignant were prepared and tested retrospectively and prospectively. Several parameters such as (scores of factor, Mahalanobis distance and spectral residuals) were explored for discrimination and very clean clustering of normal and malignant spectra was achieved. A multiparametric approach (limit test) combining all the above discrimination parameters was also considered, in order to develop unambiguous discrimination. This analysis has produced very high, 99.5%, sensitivity and specificity. Results obtained in this study thus validate Raman spectroscopy methods for discrimination of normal and malignant tissues in cervical cancers

On-line estimations of delivered radiation doses in three-dimensional conformal radiotherapy treatments of carcinoma uterine cervix patients in linear accelerator

Transmission of radiation fluence through patient′s body has a correlation to the planned target dose. A method to estimate the delivered dose to target volumes was standardized using a beam level 0.6 cc ionization chamber (IC) positioned at electronic portal imaging device (EPID) plane from the measured transit signal (S t ) in patients with cancer of uterine cervix treated with three-dimensional conformal radiotherapy (3DCRT). The IC with buildup cap was mounted on linear accelerator EPID frame with fixed source to chamber distance of 146.3 cm, using a locally fabricated mount. S t s were obtained for different water phantom thicknesses and radiation field sizes which were then used to generate a calibration table against calculated midplane doses at isocenter (D iso,TPS ), derived from the treatment planning system. A code was developed using MATLAB software which was used to estimate the in vivo dose at isocenter (D iso,Transit ) from the measured S t s. A locally fabricated pelvic phantom validated the estimations of D iso,Transit before implementing this method on actual patients. On-line dose estimations were made (3 times during treatment for each patient) in 24 patients. The D iso,Transit agreement with D iso,TPS in phantom was within 1.7% and the mean percentage deviation with standard deviation is −1.37% ±2.03% (n = 72) observed in patients. Estimated in vivo dose at isocenter with this method provides a good agreement with planned ones which can be implemented as part of quality assurance in pelvic sites treated with simple techniques, for example, 3DCRT where there is a need for documentation of planned dose delivery

Vibrational spectroscopy studies of formalin - fixed cervix tissues

Optical histopathology is fast emerging as a potential tool in cancer diagnosis. Fresh tissues in saline are ideal samples for optical histopathology. However, evaluation of suitability of ex vivo handled tissues is necessitated because of severe constraints in sample procurement, handling, and other associated problems with fresh tissues. Among these methods, formalin-fixed samples are shown to be suitable for optical histopathology. However, it is necessary to further evaluate this method from the point of view discriminating tissues with minute biochemical variations. A pilot Raman and Fourier transform infrared (FTIR) microspectroscopic studies of formalin-fixed tissues normal, malignant, and after-2-fractions of radiotherapy from the same malignant cervix subjects were carried out, with an aim to explore the feasibility of discriminating these tissues, especially the tissues after-2-fractions of radiotherapy from other two groups. Raman and FTIR spectra exhibit large differences for normal and malignant tissues and subtle differences are seen between malignant and after-2-fractions of radiotherapy tissues. Spectral data were analyzed by principal component analysis (PCA) and it provided good discrimination of normal and malignant tissues. PCA of data of three tissues, normal, malignant, and 2-fractions after radiotherapy, gave two clusters corresponding to normal and malignant + after-2-fractions of radiotherapy tissues. A second step of PCA was required to achieve discrimination between malignant and after-2-fractions of radiotherapy tissues. Hence, this study not only further supports the use of formalin-fixed tissues in optical histopathology, especially from Raman spectroscopy point of view, it also indicates feasibility of discriminating tissues with minute biochemical differences such as malignant and after-2-fractions of radiotherapy

A vibrational spectroscopy approach for monitoring radiation response in cervical cancers

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